Shoulder pain
Questionnaire/history:
Injury?
Recent overhead work?
Pain?
- Site of maximal pain?
--- On the AC joint?
--- Radiating into the biceps?--- Radiating into deltoid tuberosity (?rotator cuff tendinopathy)?
--- Anterior superior (?capsulitis)
--- Deep-seated (?glenohumeral arthritis)?
--- Generalised (?capsulitis)?
--- Neck pain?
--- Other upper limb pain?
- Pain mainly on movement?
- Pain worse at night (?capsulitis)?
- Onset and duration?Stiffness?
Instability?
Past medical history?
Family history?
Current medication?
- Analgesia?
Drug allergies?
Occupational history?
Exercise/sports?
Examination:
Inspection:
- Wasting (eg diffuse atrophy or sign of LMNL)?- Asymmetry of the shoulder girdle (eg scoliosis)?
Palpation (eg swelling, bony irregularities, tenderness):
(Note: Compare with other side)
- Sternoclavicular joint?
- Clavicle?
- Acromioclavicular joint?
- Acromion?
- Coracoid process?
- Head of humerus?
- Greater tubercle of humerus?
- Spine of scapula?
Active and passive movements (normal):
- Forward flexion (150°-180°)?
(- Extension (40°))?
- Abduction (180°)?
--- Painful arc (between 60°-120°)?
(Note: If severe cuff tears with pseudoparalysis proper abduction often not possible, but if arm is moved into a different position abduction possible)
(- Adduction (30°-40°))?
- External rotation (80°-90°)?
- Internal rotation (T4-T8)?
Special tests:
Pain and weakness?
Supraspinatus:
Empty can test (bring arm forward so that it is in the plane with the scapular which is sitting at 30 degrees with thumb pointing down and ask push against resistance)?
Subscapularis:
Bear hug test (bring hand onto the abdomen and ask to externally rotate against resistance)?
External rotation of both shoulders (noting that main restrain to external rotation caused by subscapularis and that affected side externally rotates a bit more)?
Infraspinatus:
Infraspinatus test (external rotation against resistance)?
Teres minor:
Hornblower’s sign (maximal external rotation in the abducted position against resistance)?
Biceps:
Yergason’s test (supination against resistance)?
ACJ:
Scarf test (cross-body adduction)?
Diagnoses:
Fracture
ACJ disorder
Biceps pathology
Glenohumeral OA
Capsulitis
Rotator cuff disorder
Instability
- Polar I
- Polar III
- Polar III
Referred pain
- From neck
- From heart
- From lung
Polymyalgia rheumatica
Management:
According to cause
Reference(s):
Aresti, N: Fleet Street Clinic CPD talk: ‘Shoulder dislocation’, HCA Healthcare UK, 2023
BESS/BOA Shoulder Pain Guideline for Primary Care 2020
Geeky Medics (2021): Shoulder exam
Other info:
Joint infection?
Red skin?
Fever?
Systematically unwell?
-> Same-day emergency referral
Unreduced traumatic shoulder dislocation?
-> Same-day emergency referral
Malignancy?
Referred pain from apical lung cancer?
Mass?
Swelling?
Unexplained deformity?
Night pain?
Previous cancer?
-> 2-week cancer referral
Systemic/widespread symptoms (eg PMR, inflammatory arthritis)?
Referred pain to the shoulder or pain not primary from the shoulder?
- Cervical spinal pathology?
- Diaphragmatic pain (shoulder tip pain)?
- Malignancy (eg metastasis or apical lung tumour)?
- PMR (bilateral with early morning stiffness +/- systemic features)?
Acute Presentations:
Acute rotator cuff tears?
Questionnaire/history:
Shoulder trauma?
Pain in the shoulder or lateral aspect of the arm?
Unable to abduct the arm above shoulder level (especially if not limited by pain)?
Management:
X-ray to rule out fracture
If no fracture and < 2 weeks since injury: rest and activity modification and review if symptoms no better in 2 weeks
If symptoms no better > 2 weeks after the injury, refer urgently to orthopaedics for imaging
(Notes: Often need consideration of surgery and if delayed the surgery can be difficult (or impossible)
Incidence of acute cuff tears in those > 40 years old after shoulder dislocation may be as high as ~50%)
Traumatic instability?
Management:
Refer urgently to orthopaedics (probably fracture clinic)
(Note: Younger patients are at risk of labral injury and high risk of recurrence, older patients are at risk of acute cuff tear)
Acromioclavicular Joint Injury?
Diagnosis:
Grade 1: Intact joint - minor tear of AC ligaments
Grade 2: < 50% vertical subluxation with rupture of AC ligament and stretching of coracoclavicular ligaments
Grade 3: >50% vertical subluxation with rupture of AC and coracoclavicular ligaments
Management:
Refer for XR or to A+E depending on clinical judgement
If grade 1 or 2: conservative management with rest, polysling, analgesia, and gentle mobilisation
If grade 3 refer shoulder specialist